GOMEZ-1
ACORD e
CERTIFICATE OF LIABILITY INSURANCE
~
OP ID: SM
DATE (MM/DD/YYYY)
I
03/07/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
~~~~ACT Susan Muniz
r.~,?N.Tn c~•· 210-253-2415
~oMDA~~ss: susan~trimble-batjer.com
PRODUCER
Trimble-Batjer San Antonio
120 Austin Hwy., Ste. 103
San Antonio, TX 78209
Barbara Newcomb
Irffc
Nol :
210-308-9540
INSURER(S) AFFORDING COVERAGE
Gomez Floor Covering Inc.
dba GFC Contracting
3816 Binz-Engleman Ste. B125
San Antonio, TX 78219
INSURED
INSURER A : Liberty
Mutual Fire Insurance
INSURER B : Liberty
Insurance Corporation
NAIC#
INSURER C :
INSURER D :
INSURER E :
INSURER F :
COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS ,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS .
INSR
LTR
ADDL SUBR
TYPE OF INSU RANCE
-
A
'"CD """"
POLIC Y NUMBER
POLICY EFF
POLICY EXP
IM
GENERAL LIABILITY
x
TB2Z91461908055
COMMERCIAL GENERAL LIABILITY
12/3 1/2015
12/31/2016
I CLAIMS-MADE [ ! ] OCCUR
-x
SEE BELOW
GEN'L AGGREGATE LIMIT APPLIES PER:
I
-x
POLICY
lxl ~~c?,:
f-f--
x
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
1,000,000
$
100,00C
MED EXP (Any one person)
$
5,000
PERSONAL & ADV INJURY
$
1,000,000
GENERALAGGREGATE
$
2,000,000
PRODUCTS - COMP/OP AGG
$
2,000,000
$
AS2Z91461908025
-
-
$
nLoc
AUTOMOBILE LIABILITY
A
LIMITS
EACH OCCURRENCE
UAMAGt: I U r<coi" c: u
PREMISES IEa occurrence)
x
12/31/2015
12/31/2016
SCHEDULED
AUTOS
NON-OWNED
AUTOS
COMBINED SINGLE LIMIT
(Ea accidentl
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(PER ACCIDENn
$
$
SEE BELO
x
B
UMBRELLA LIAB
B
~ OCCUR
EXCESSLIAB
OED
1,000,000
I x I RETENTION $
TH7Z91461908045
CLAIMS-MADE
12/31/2015
12/31/2016
10000
WORKERS COMPENSATION
AND EMPLOYERS" LIABILITY
Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
[NJ
EACH OCCURRENCE
$
10,000,000
AGGREGATE
$
10,000,000
x I TORY
WC STATU- I
IMIT!":
I
N/A
WC7Z91461908096
03/09/2016
12/31/2016
SEE BELOW
s
IOJ~$
1,000,000
E.L. DISEASE - EA EMPLOYEE $
1,000,000
E.L. DISEASE - POLICY LIMIT
1,000,000
E.L. EACH ACCIDENT
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101 , Add itional Rema r ks Schedule, if more s pace is required)
SEE REVERSE F OR SPECIAL PROVISIONS
CANCELLATION
CERTIFICATE HOLDER
STENA TX
Stephen F. Austin State
University
Purchasing Dept
P.O. Box 13030
1Nacoadoches TX 75962-3030
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
~'/ct/~
© 1988-2010 ACORD CORPORATION. All rights reserved .
ACORD 25 (2010/05)
The ACORD name and logo are registered marks of ACORD
NOTEPAD
1NsuRED's NAME
Gomez Floor Covering Inc.
GOMEZ-1
OP ID: SM
***SPECIAL PROVISIONS-Policies include a blanket 30 day notice of
cancellation/material change endorsement (except nonpay,10), a blanket
additional insured (except WC), with general liability including
products/completed operations, primary and non- contributory coverage, and
a blanket waiver of subrogation endorsement all in favor of any person or
organization as required by signed , written contract.
WE HAVE ISSUED AN INDUSTRY STANDARD ACORD CERTIFICATE OF INSURANCE FOR OUR
CUSTOMER . A LAW PASSED BY THE TEXAS LEGISLATURE EFFECTIVE JANUARY 1, 2 012
(SENATE BILL 425) PROHIBITS US FROM ADDING SPECIAL WORDING TO THE
CERTIFICATE THAT WOULD (l)ALTER , AMEND OR EXTEND COVERAGE OR TERMS AND
CONDITIONS PROVIDED BY THE INSURANCE POLICY ; AND (2)PROVIDE FALSE OR
!MISLEADING INFORMATION CONCERNING THE INSURANCE POLICY; OR (3) REFER TO A
LEGAL OR INSURANCE REQUIREMENT CONTAINED IN A CONTRACT.
Date
PAGE 2
03/07/2016